Murray E. Brandstater

Motor unit number estimate-based rates of progression of ALS predict patient survival.

We have examined, as predictors of survival in patients with amyotrophic lateral sclerosis (ALS), linear estimates of rates of disease progression (LEP), based on motor unit number estimates (MUNE). Motor unit number estimates of thenar, hypothenar, and extensor digitorum brevis muscles (according to the manual method of McComas), isometric grip and foot dorsiflexion (FD) strength, and forced vital capacity (FVC) were available in 34 patients. Linear estimates of rates of disease progression were derived. Probability of survival was calculated using the Kaplan–Meier method. Motor unit number estimates, LEP based on MUNE, and demographic characteristics were tested as risk factors within the Cox Proportional Hazards Model, using regression techniques. Individually, all MUNE‐based LEP were highly significant (P < 0.00005); bulbar onset attained modest significance (P = 0.044). Secondary analysis showed MUNE‐based LEP were more significant than regionally concordant function‐based LEP. Linear estimates of rates of disease progression based on MUNE may thus predict survival of patients with ALS better than LEP based on function.

The Effects of Peroneal Nerve Functional Electrical Stimulation Versus Ankle-Foot Orthosis in Patients With Chronic Stroke A Randomized Controlled Trial

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. Objective. To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. Methods. In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. Results. A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. Conclusions. Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Long-Term Follow-up to a Randomized Controlled Trial Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke:

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. Objective. Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. Methods. Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). Results. A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. Conclusions. At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

Painless electrodiagnostic current perception threshold and pain tolerance threshold values in CRPS subjects and healthy controls: a multicenter study.

Abstract: The purpose of this study is to evaluate both painless and painful sensory transmission in patients with Complex Regional Pain Syndrome (CRPS) using the automated electrodiagnostic sensory Nerve Conduction Threshold (sNCT) test. This test generates reliable, painless Current Perception Threshold (CPT) and atraumatic Pain Tolerance Threshold (PTT) measures. Standardized CPT and PTT measures using constant alternating current sinusoid waveform stimulus at 3 different frequencies 5 Hz, 250 Hz, and 2 kHz (Neurometer® CPT/C Neurotron, Inc. Baltimore, MD) were obtained from CRPS subjects at a distal phalange of the affected extremity and at an ipsilateral asymptomatic control site. Matched sites were tested on healthy subjects. Detection sensitivities for an abnormal PTT and CPT test were calculated based on specificity of 90% as determined from data obtained from healthy controls. A Spearman rank correlation was used to test for a significant association between presence of allodynia and an abnormal PTT or CPT at any frequency tested. Thirty‐six CRPS subjects and 57 healthy controls were tested. The highest detection sensitivity of the PTT test from symptomatic test sites was 63% for the finger and 71% for the toe. PTT abnormalities were also detected, to a lesser degree, at the asymptomatic control site (41% finger control site, 16% toe control site). The highest CPT detection sensitivity at the symptomatic site was 37% for the finger site and 53% for the toe site. CPT abnormalities were also detected at the asymptomatic control site (29% finger control site, 37% toe control site). Eighty‐six percent of the CRPS subjects had either a PTT or CPT abnormality at any frequency at the symptomatic site. There was a significant correlation between presence of allodynia and presence of an abnormal CPT and PTT, respectively (P < .01). The correlation coefficient was lower for CPT than for PTT, ie, 0.34 versus 0.6 for the finger and 0.48 versus 0.67 for the toe, respectively. In studied CRPS patients an abnormal PTT was detected with higher sensitivity than an abnormal CPT. Assessing PTT may become a useful electrodiagnostic quantitative sensory test for diagnosing and following the course of neuropathic pain conditions.

Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.

BACKGROUND Elderly persons with traumatic brain injury (TBI) are increasingly admitted to inpatient rehabilitation, but we have limited knowledge of their characteristics, the treatments they receive, and their short-term and medium-term outcomes. This study explored these issues by means of comparisons between age groups. METHODS Data on 1419 patients admitted to 9 inpatient rehabilitation facilities for initial rehabilitation after TBI were collected by means of (1) abstraction from medical records; (2) point-of care forms completed by therapists after each treatment session; and (3) interviews at 3 months and 9 months after discharge, conducted with the patient or a proxy. RESULTS Elderly persons (65 or older) had a lower brain injury severity, and a shorter length of stay (LOS) in acute care. During rehabilitation, they received fewer hours of therapy, due to a shorter LOS and fewer hours of treatment per day, especially from psychology and therapeutic recreation. They regained less functional ability during and after inpatient rehabilitation, and had a very high mortality rate. CONCLUSIONS Elderly people can be rehabilitated successfully, and discharged back to the community. The treatment therapists deliver, and issues surrounding high mortality need further research.

Swallowing, Nutrition, and Hydration During Acute Stroke Care

Abstract Dysphagia occurs in up to half of patients after an acute stroke and may cause dehydration, undernutrition, and aspiration pneumonia. Current evidence suggests that a systematic program of diagnosis and treatment of dysphagia in an acute stroke management plan may yield dramatic reductions in aspiration pneumonia rates. There is also some evidence that nutritional supplementation and proper hydration may reduce morbidity and mortality in acute stroke patients. This article focuses on the recent advances in the evaluation and management of dysphagia, undernutrition, and dehydration related to acute stroke. A summary of pertinent studies in the area of stroke dysphagia and nutrition is also included.

Basic Aspects of Impairment Evaluation in Stroke Patients

Focal brain lesions caused by stroke confer on the patient a set of neurological deficits. These deficits are called impairments. Evaluation of these impairments constitutes an essential first step in management of the patient. In the acute patient, evaluation of the impairments helps the physician determine the pathology, localization, and severity of the lesion. For rehabilitation, evaluation of the impairments helps the clinician determine functional prognosis, establish rehabilitation goals, and define the treatment program. The key neurological impairments observed in stroke patients may be grouped under the following headings: mental status, communication, cranial nerves, motor function, sensory function, and posture and balance. Evaluation methods for some of the deficits have been refined through the development of scaled tests, allowing quantification. Use of scores from scaled tests allows the clinician to rate severity of the impairment and to monitor recovery.

Physical Medicine and Rehabilitation and Acute Inpatient Rehabilitation

D Postacute medical rehabilitation provides care to people with a disability after a recent hospitalization due to trauma or illness, and has as its main goal functional improvement for these individuals to help them prepare to live as independently as possible. Postacute care (PAC) encompasses a wide range of services offered in different settings, including inpatient rehabilitation facilities (IRFs), outpatient therapy, services provided in the home by home health agencies, long-term care hospitals, and skilled nursing facilities. PAC involves rehabilitation, but the intensity and nature of the rehabilitation provided in these different levels of care vary. The amount and intensity of therapy are determined by the needs of the patient, statutory requirements, and payment policies. A number of factors have led to an increasing demand for postacute rehabilitation services. The value of postacute rehabilitation has been recognized for many years by the public, health care professionals, and insurers, and the health care industry has responded by expanding the volume of services that provide postacute rehabilitation. Although rehabilitation services are provided to patients of all ages, from young children to the elderly, older adults in particular have fueled this increased demand due to the growth in their numbers and because they have a higher incidence of disabling conditions, such as stroke, arthritis, hip fracture, and amputation. Furthermore, the patterns of care in acute hospitals are becoming more complex, and higher acuity patients, with more comorbidities, are increasingly being referred for PAC. Many of these medically complex patients are being admitted into IRFs, and many more who need less intense care are being managed in their homes or skilled nursing facilities.

Prognostication in Stroke Rehabilitation

Good early prediction of ultimate outcome following stroke rehabilitation benefits patients and health care professionals. Numerous research studies have reported stroke outcomes, but the conclusions are not always in agreement because of differences in study methodology and in patient characteristics. However, some general conclusions about prognostication can be made. Early survival is poorer in those patients who have cerebral hemorrhage, coma at onset, or heart disease. Recovery from neurological impairment such as hemiplegia is influenced by lesion-related variables such as lesion size and location. Recovery from hemiplegia follows a predictable pattern, with most motor recovery occurring within the first 6 months. The disability status of stroke patients at late follow-up depends most on initial activities of daily living (ADL) scores recorded post onset. Characteristics that predict a less favorable outcome are older age and presence of urinary incontinence, bowel incontinence, and visuospatial deficits. Social and psychological variables, especially prestroke family interaction and presence of an able spouse, may strongly influence ultimate disability status and the return of patients to their home.

Poster 519 Acute Cervical Myelopathy Caused By Chiropractic Manipulation in a Young Person With a Cervical Osteochondroma: A Case Report

diagnoses. Design: Prospective cohort study. Setting: Acute inpatient rehabilitation facility. Participants: 78 inpatients. Interventions: Weekly calorie and protein intake calculations by registered dieticians. Main Outcome Measures: Mean calorie and protein intake. Results: Mean calorie intake (kcal) for the SCI, traumatic brain injury (TBI), Stroke, and Parkinson’s groups was 1967.9 611.6, 1546.8 352.3, 1459.7 443.2, and 1459.4 434.6, respectively. ANOVA revealed a significant overall group difference [F(3,74) 4.74, P .004]. Pairwise comparisons showed significant differences between SCI and Stroke (P .003) and SCI and Parkinson’s (P .045). Mean calorie intake per body weight (kcal/kg) for the SCI, TBI, stroke, and Parkinson’s groups was 24.4 9.8, 20.4 5.3, 17.4 8.4, and 19.2 6.6, respectively. ANOVA again revealed a significant overall group difference [F(3,74) 2.84, P .044]; however, pairwise comparison only found a significant difference between SCI and Stroke (P .025). Mean protein intake (g) for the SCI, TBI, Stroke, and Parkinson’s groups was 71.5 25.0, 61.1 12.8, 57.6 16.6, and 55.1 19.1, respectively. ANOVA revealed a marginally significant overall group difference [F(3,74) 2.50, P .066]. Pairwise comparisons only found a marginally significant difference between SCI and Stroke (P .060). Mean protein intake per body weight (g/kg) for the SCI, TBI, Stroke, and Parkinson’s groups was 0.89 0.39, 0.81 0.18, 0.68 0.29, and 0.73 0.28, respectively. ANOVA did not reveal a significant difference between the groups [F(3,74) 1.97, P .126]. Conclusions: Given the diet-related comorbidities and decreased resting metabolic rate associated with SCI patients in combination with the intake levels demonstrated in this study, education with regard to appropriate calorie and protein intake in patients with SCI should be employed in the acute inpatient rehabilitation setting.